TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 1 Prevention of Dental Caries

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 2 Outline Discuss the current evidence on use of fluoride in prevention of the initiation and progression of dental caries

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 3 Fluoride Water fluoridation Toothpaste and gels (dentifrice) Additional topical fluoride applications at home: rinses, and high concentration fluoride dentifrices Professionally applied fluoride applications

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 4 Mechanisms of Action

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 5 FLUORIDE MECHANISMS TO PREVENT CARIOUS LESION PROGRESSION Remineralization of initial lesions. F, Ca, PO4 Ions from plaque move into demineralized enamel when pH drops. Interference with bacterial metabolism by inhibiting the enzyme glucosyltransferase. At high concentrations, F is bactericidal. May increase the resistance of enamel to acid solubility by pre-eruptive incorporation into the hydroxyapatite crystal. Reference: Journal of Dental Research 1990;69(Spec Issue).

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 6 CONCLUSIONS FROM THE STUDY OF HAYES AND COLLEAGUES FROM GRAND RAPIDS STUDY, 1956 “The decrease in caries appeared to be greater for deeper lesions than for shallow lesions.” “The decrease in the deeper lesions without a balancing increase in the shallow lesions suggests that fluoride retards the development of caries and that it also prevents the inception of caries.”

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 7 Fluoride works best to prevent and control dental caries when a small concentration is constantly present in the oral cavity. The goal of any fluoride program is thus to achieve and maintain this status through frequent exposure to low-concentration fluorides: toothpastes, drinking water, fluoridated salt, rinses, varnishes.

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 8 FLUORIDE IN DENTAL PLAQUE Plays a vital role in remineralization Plaque usually has 5-10 ppm F (wet weight) Less than 5% free ions, the rest is bound Plaque F levels rise with exposure to F; the higher the F content of the exposure, the higher plaque F levels will become Plaque F levels soon drop without continued introduction of F into the mouth

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 9 FLUORIDE IN SALIVA Resting saliva levels are 70% - 80% of plasma F levels. When drinking water is 0.1 ppm F, saliva is ppm F When drinking water is 1.2 ppm F, saliva is ppm F Saliva F levels rise exponentially (100- to 1,000- times) when F is introduced into the mouth. Baseline levels return within 3-6 hours. This difference is considered to be of no clinical importance.

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 10 Water Fluoridation

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 11 Fluoridation is the controlled addition of a fluoride compound to a public water supply in order to bring its fluoride concentration up to an optimum level for preventing and controlling dental caries. /

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 12 CARIES IN THE GRAND RAPIDS STUDY 15 y-o 13 y-o 11 y-o 9 y-o Birth Cohort

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 13 CARIES IN BRITISH CHILDREN AGED 12 WHEN FLUORIDATION STARTED 27% Less

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 14 AGE-STANDARDIZED MEAN DMFT FOR 7-14 y-o CHILDREN IN NEWBURGH (1.0 ppm F) AND KINGSTON (0.1 ppm F) OVER 50 YEARS

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 15 FLUORIDATION AND SOCIAL CLASS IN 12-y-o BRITISH CHILDREN. ( Murray et al, 1991). Hartlepool 1.3 ppm F Newcastle 1.0 ppm F Middlesbrough 0.2 ppm F

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 16 CA RIES EXPERIENCE BY SOCIAL CLASS AMONG BRITISH 5-year-olds IN FLUORIDATED AND NON-FLUORIDATED AREAS: County Durham (Provart and Carmichael 1995). Fluoridated Non-Fluoridated

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 17 FLUOROSIS IN DEAN’S STUDIES IN THE 1930s

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 18 Water Fluoridation: Current Recommendations Initial studies of community water fluoridation demonstrated that reductions in childhood dental caries attributable to fluoridation were approximately 50%--60% (94--97). More recent estimates are lower %--40% (98,99). This decrease in attributable benefit is likely caused by the increasing use of fluoride from other sources, with the widespread use of fluoride toothpaste probably the most important. The diffusion or "halo" effect of beverages and food processed in fluoridated areas but consumed in nonfluoridated areas also indirectly spreads some benefit of fluoridated water to nonfluoridated communities. This effect lessens the differences in caries experience among communities (100). CDC Recommendations. MMWR 2001

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 19 Water Fluoridation: Current Recommendations Fluoride concentrations in drinking water should be maintained at optimal levels, both to achieve effective caries prevention and because changes in fluoride concentration as low as 0.2 ppm can result in a measurable change in the prevalence and severity of enamel fluorosis. CDC Recommendations. MMWR 2001

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 20 Water Fluoridation: University of Your Systematic review 214 studies were included. The quality of studies was low to moderate. Water fluoridation was associated with an increased proportion of children without caries and a reduction in the number of teeth affected by caries. The range of mean differences in the proportion of children without caries was 5.0% to 64% (14.6%). The range of mean change in decayed, missing, and filled primary/permanent teeth was 0.5 to 4.4 (2.25) teeth. A dose-dependent increase in dental fluorosis was found. BMJ 2000;321: ( 7 October ). Systematic review of water fluoridation a NHS Centre for Reviews and Dissemination, University of York, York

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 21 Fluoridated Dentifrices Seventy-four studies were included. For the 70 that contributed data for meta-analysis (involving 42,300 children) the D(M)FS pooled PF was 24% (95% confidence interval (CI), 21 to 28%; P < ). This means that 1.6 children need to brush with a fluoride toothpaste (rather than a non-fluoride toothpaste) to prevent one D(M)FS in populations with caries increment of 2.6 D(M)FS per year. In populations with caries increment of 1.1 D(M)FS per year, 3.7 children will need to use a fluoride toothpaste to avoid one D(M)FS. There was clear heterogeneity, confirmed statistically (P < ). The effect of fluoride toothpaste increased with higher baseline levels of D(M)FS, higher fluoride concentration, higher frequency of use, and supervised brushing, but was not influenced by exposure to water fluoridation. There is little information concerning the deciduous dentition or adverse effects (fluorosis). Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD DOI: / CD

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 22 Professionally Applied Topical Fluorides

GradeCategory of Evidence IaEvidence from systematic reviews of randomized controlled trials IbEvidence from at least one randomized controlled trial IIaEvidence from at least one controlled study without randomization IIbEvidence from at least one other type of quasi- experimental study IIIEvidence from non-experimental descriptive studies, as comparative studies, correlation studies, cohort studies and case-control studies IVEvidence from expert committee reports or opinions or clinical experience of respected authorities

ClassificationStrength of Recommendations ADirectly based on category I evidence BDirectly based on category II evidence or extrapolated recommendation from category I evidence CDirectly based on category III evidence or extrapolated recommendation from category I or II evidence DDirectly based on category IV evidence or extrapolated recommendation from category I, III or III evidence

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 25 Panel Conclusions Fluoride gel is effective in preventing caries in school-children (Ia). Patients whose caries risk is low, as defined by the panel, may not receive additional benefit from professional topical fluoride applications (Ia). Four-minute professionally applied F gels are supported by evidence (Ia); however, there is no clinical equivalency data to support the 1-minute fluoride gel application (IV).

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 26 Panel Conclusions Fluoride varnish applied every six months is effective in preventing caries in the primary and permanent dentitions of children and adolescents (Ia). Two or more applications of fluoride varnish per year are effective in preventing caries in high-risk populations (Ia).

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 27 Panel Conclusions  Fluoride varnish applications take less time, create less patient discomfort and achieve greater patient acceptability than do fluoride gel applications, especially in preschool children (III).  Four-minute fluoride foam applications, every six months, are effective in caries prevention in the primary dentition and newly erupted permanent first molars (Ib).  There is insufficient evidence to address whether or not there is a difference in the efficacy of NaF versus APF gels (IV).

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 28 Clinical Recommendations Caries risk (low, medium, high) –Appropriate preventive dental treatment (including fluoride therapy) can be planned after identification of caries risk status. –Caries risk status should be evaluated periodically. –The panel concluded that there is no single widely accepted risk assessment system. –Dentists, however, can use simple clinical indicators.

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 29 High Caries Risk Younger than 6 years (any of the following) –Any incipient or cavitated primary or secondary carious lesion during the last three years –Presence of multiple factors that may increase caries risk (high titers of cariogenic bacteria, poor oral hygiene, prolonged nursing [bottle or breast]) –Low socioeconomic status –Suboptimal fluoride exposure –Xerostomia (medication-, radiation-, or disease- induced)

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 30 Clinical Recommendations High-caries risk – < 6 years Varnish application at 6-month intervals (A) Varnish application at 3-month intervals (D) –6 to <18 years Varnish or gel applications at 6 month intervals (A) Varnish application at 3-month intervals (A) Gel application at 3-month intervals (D) –18 years Varnish or gel applications at 3- or 6-month intervals (D)

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 31 Clinical Recommendations Low-caries risk – < 6 years and 6-18 years May not receive additional benefit from professional topical fluoride application (B) (Fluoridated water and dentifrices may provide adequate prevention) –18+ years May not receive additional benefit from professional topical fluoride application (D)

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 32 Other Considerations The available evidence on fluoride foam is weak and the Panel did not make a recommendation. Application time for fluoride gel and foam should be four minutes.

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 33 ADA Clinical Recommendation on Sealants

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 34 ADA Clinical Recommendations Pit and fissure sealants can be used effectively as part of a comprehensive approach for caries prevention on an individual basis or as a public health measure for at-risk populations.

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 35 ADA Clinical Recommendations Sealants are placed to prevent caries initiation and to arrest caries progression by providing a physical barrier that inhibits micro-organisms and food particles from collecting in pit and fissure surfaces.

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 36 ADA Clinical Recommendations It is generally accepted that the effectiveness of sealants for caries prevention is dependent on long-term retention. Full retention of sealants can be evaluated through visual and tactile exams. In situations where a sealant has been lost or partially retained, the sealant should be reapplied to ensure effectiveness.

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 37 ADA Clinical Recommendations Pit and fissure sealants are currently underutilized, particularly among those at high risk for caries, including children in lower income and certain racial and ethnic groups. The national oral health objectives for dental sealants, as stated in the US Department of Health and Human Services initiative Healthy People 2010, includes increasing the proportion of children who have received dental sealants on their molar teeth to 50 percent.

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 38 ADA Clinical Recommendations US national data indicate that sealant prevalence on permanent teeth among children aged 6 to 11 years is 30.5 percent but represents a substantial increase over the 8 percent prevalence reported in

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 39 ADA Clinical Recommendations Placement of resin-based sealants on the permanent molars of children and adolescents is effective for caries reduction. Ia Reduction of caries incidence after placement of resin-based sealants ranges from 86 percent at one year, to 78.6 at two years, and 58.6 percent at four years in children and adolescents. Ia

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 40 ADA Clinical Recommendations Sealants are effective in reducing occlusal caries incidence in permanent first molars of children, with caries reductions of 76.3 percent at four years when sealants were reapplied as needed. Caries reduction was 65 percent at nine years from initial treatment, with no reapplication during the last five years. Ib

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 41 ADA Clinical Recommendations Pit and fissure sealants are retained on primary molars at a rate of 74.0 to 96.3 percent at one year, 59 and 75 percent at 2.8 years. III There is consistent evidence from private dental insurance and Medicaid databases that placement of sealants on first and second permanent molars in children and adolescents is associated with reductions in the subsequent provision of restorative services. III

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 42 ADA Clinical Recommendations Placement of pit-and-fissure sealants significantly reduces the percentage of non-cavitated carious lesions that progress in children, adolescents and young adults up to five years after sealant placement, compared with unsealed teeth. Ia

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 43 ADA Clinical Recommendations Sealants should be placed in children on pits and fissures of primary teeth when it is determined that the tooth, or the individual, is at risk for caries. III, D Sealants should be placed in children and adolescents on pits and fissures of permanent teeth when it is determined that the tooth, or the individual, is at risk for caries. Ia, B Sealants should be placed in adults on pits and fissures of permanent teeth when it is determined that the tooth, or the individual, is at risk for caries. Ia, D

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 44 ADA Clinical Recommendations Pit and fissure sealants should be placed on early (non-cavitated) carious lesions … in children, adolescents and young adults, to reduce the percentage of lesions that progress. Ia, B Pit and fissure sealants should be placed on early (non-cavitated) carious lesions, as defined in this document, in adults, to reduce the percentage of lesions that progress. Ia, D

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 45 ADA Clinical Recommendations Resin-based sealants are the first choice of material for dental sealants. Ia, A Glass ionomer cement may be used as an interim preventive agent when there are indications for placement of a resin-based sealant but concerns about moisture control may compromise the placement of a resin- based sealant. IV, D

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 46 ADA Clinical Recommendations A compatible one-bottle bonding agent, which contains both an adhesive and a primer, between the previously acid-etched enamel surface and the sealant material may be used when, in the opinion of the dental professional, retention may be enhanced in the clinical situation. Ib, B Presently available self-etching bonding agents, which do not involve a separate etching step, may provide less retention than the standard acid etching technique and are not recommended. Ib, B

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 47 ADA Clinical Recommendations Routine mechanical preparation of enamel before acid etching is not recommended. IIb, B Use a four-handed technique while placing resin-based sealants, when possible. III, C Use a four-handed technique while placing glass ionomer cement sealants, when possible. IV, D Monitor and reapply sealants as needed to maximize effectiveness. IV, D

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 48 Sealants: Conclusions Sealants are effective as primary and secondary preventive materials. Sealants should be applied to at-risk teeth within an integrated oral health promotion and prevention program. Sealants require re-evaluation on a regular basis. Sealants should be part of a comprehensive oral health promotion and prevention program that provides dental care.